VESSEL ENTRY APPLICATION

Please enter in the Association the under mentioned vessel, subject to the Rules, receipt of which we acknowledge:

Vessel Details
Vessel Name: Gross Tonnage: Hull Type:
Flag: Year Built: IMO / Lloyds No.
Port of Registry: Vessel Type: Class Society:
Call Sign: Passenger Capacity:

Cover Required
Class 1 – P&I : Commencement Date of Risk:
Class 2 – FDD : Commencement Date of Risk:

Officers Nationality: Number: Trading Areas

Other Crew Nationality: Number:

International Safety Management (ISM) Operating Company:

Safety Management Certificate (SMC) Document of Compliance (DOC)
Date of Issue: Date of Issue:
Date of Expiry: Date of Expiry:
Full or Interim: Full or Interim:
Certification Body: Certification Body:

Assureds
Principal Member Capacity (owner, bareboat Registered Company
(name & address, registered and business) charterer, manager etc) Number

Co-Assured Members Capacity (owner, bareboat Registered Company

(name & address, registered and business) charterer, manager etc) Number

Name of Assured to be Premium Invoicee Name of Assured to be Claim Payee

Name & Address for Correspondence Tel:

Fax:
E-Mail:
Website:

Signed
Name: Email:
Position: Date:
Company:

STEAMSHIP INSURANCE MANAGEMENT SERVICES LIMITED

Authorised and regulated by the Financial Conduct Authority
AQUATICAL HOUSE 39 BELL LANE LONDON E1 7LU
Tel: +44 20 7247 5490 Website: www.steamshipmutual.com
(Registered in England and Wales – Registration number 3855693. FCA registration number 314468)